Chapter 86: Bipolar Disorder

KEY CONCEPTS

• Bipolar disorder is a cyclic mental illness with recurrent mood episodes that occur over a person’s lifetime. The symptoms, course, severity, and response to treatment differ among individuals.

• Bipolar disorder is likely caused by genetic factors, environmental triggers, and the dysregulation of neurotransmitters, neurohormones, and second messenger systems in the brain.

• Clinicians should obtain a detailed history, including substance use history and medical history, to expedite the diagnosis and treatment of bipolar disorder.

• Bipolar disorder is a complex psychiatric illness with significant morbidity and mortality. Suicidal thoughts and behaviors are common in individuals with bipolar disorder and need to be managed with medical and therapeutic interventions.

• The goal of therapy for bipolar disorder should be to improve patient functioning by reducing mood episodes. This is accomplished by maximizing adherence to therapy and limiting adverse effects.

• Patients and family members should be educated about bipolar disorder and treatments. Long-term monitoring and adherence to treatment are primary factors in achieving stabilization of the disorder.

• Lithium, valproate, and second-generation antipsychotics are the mainstays of treatment for different phases of bipolar disorder, acting as primary mood stabilizers. When individuals with bipolar disorder present with an acute mood episode (depressed episode, manic episode or mixed state) despite a primary mood stabilizer, adjunctive medications are considered to target the specific mood state or subtype. These medications can often be tapered once the acute episode has resolved and the patient is euthymic. Baseline and follow-up laboratory tests are required for most medications for bipolar disorder to monitor for adverse effects.

• Some patients can be stabilized on one mood stabilizer, but others may require combination therapies or adjunctive agents during an acute mood episode. If possible, adjunctive agents should be tapered and discontinued when the acute mood episode remits and the patient is stabilized. Adjunctive agents may include benzodiazepines, additional mood stabilizers, antipsychotics, and/or antidepressants.

Patient Care Process for Bipolar Disorder

Collect

• Patient characteristics (eg, age, race, sex, pregnant)

• Patient psychiatric, medical, social, and family history

• Current medications and prior medication use

• Current and past sleep habits/patterns

• Objective data

  • BP, heart rate, height, weight, and BMI

  • Laboratory test (eg, serum electrolytes, Scr, LFTs, TSH)

  • Rating scale scores (YMRS, HAM-D, PHQ-9)

Assess

• Presence of hypomania, mania, or depression

• Adherence to medication regimen

• Appropriateness and effectiveness of current medication regimen

• Serum concentration of medication if appropriate (eg, lithium)

• Current medications that may contribute to or worsen mania or depression

• Suicidality

• Current sleep patterns

• If no response to current medication regimen, reassess diagnosis

Plan^*

• If euthymic, continue current regimen if appropriate

• If manic, immediately discontinue antidepressant, optimize regimen, and consider short-term use of benzodiazepine (see Table 86-4)

• If depressed, optimize regimen and consider ...